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Endoscopy in surgery
- 1. ENDOSCOPY IN SURGERY NUR IZZATULNAJWA BINTI SHARUPUDDIN 082015100036
- 2. LEARNING OBJECTIVES At theend of this seminar, we should be able to understand : • The definition of endoscopy and endoscope • Upper & lower GI endoscopy • The indication for diagnostic and therapeutic endoscopy/ colonoscopy/ endoscopic retrograde cholangiopancreatography • The recognition and management of complications • Briefly on other types of endoscopy, • Endoscopic ultrasound • Respiratory • Cystoscopy
- 3. • Endoscopy GreekWord ‘Endo’ = Inside ‘scopy ‘= to see ENDOSCOPY Examination of the interior of a canal or hollow viscus by means of a special instrument, such as an endoscope ENDOSCOPE Device using fiber optics and powerful lens systems to provide lighting and visualization of the interior of cavity. The portion of the endoscope inserted into the body may be rigid or flexible, depending upon the medical procedure. INTRODUCTION
- 4. The digestive tractconsists of the followings : • Mouth • Throat • Esophagus • Stomach • Duodenum • Small bowel • Colon • Rectum • Anus • And other GI organs . INTRODUCTION
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- 6. • Involves theuse of a side- viewing duodenoscope - passed through the pylorus and into the second part of the duodenum - to visualise the papilla • It is cannulated directly with catheter/ guidewire – requires small precut • Visualised under fluroscopy after contrast injection ENDOSCOPIC RETROGRADE CHOLANGIOPANCREA TOGRAPHY (ERCP)
- 8. Preoperative procedure : •Routineblood screening including clotting screen •Respiratory & cardiovascular assessment •Oxygen saturation monitoring THERAPEUTIC ERCP
- 9. Indication : •Relief biliaryobstruction – gallstone & biliary stricture If there is delay in reliefing – require percutaneous drainage Adequate biliary sphincterotomy normally performed over well positioned guidewire Gallstones <1 cm will pass spontaneously in days & weeks Most endoscopists prefer to ensure duct clearance at initial procedure to reduce risk of impaction, cholangitis / pancreatitis Trawling of duct using balloon catheter / extraction using wire basket If standard techniques fail – mechanical lithotripsy is done – placement of removable plastic stent Correct stent placement confirmed by flow of bile after release & presence of air in biliary tree on follow up radiographs
- 11. Other indications : •Pancreatic disease • Pancreatic stone extraction • Dilatation of pancreatic duct strictures • Transgastric drainage of pancreatic pseudocysts • Assessment of biliary dysmotility (sphincter of Oddi dysfunction) THERAPEUTIC ERCP
- 12. • Duodenal perforation(1.3%)/hemorrhage after scope insertion/ sphincterotomy (1.4%) • Pancreatitis (4.3%) • Sepsis (3-30%) • Mortality (1%) Post sphincterotomy complications : • CT scan required in patients with pain, tachycardia / hypotension postprocedure • Can be severe – extensive pancreatic necrosis • Recommended to administered per-rectal indomethacin/diclofenac immediately before / after procedure – to decrease post ERCP pancreatitis COMPLICATIONS OF ERCP
- 13. RISK FACTORS FORPOST – ERCP PANCREATITIS Definite Suspected SOD Young age Normal bilirubin Prior ERCP – related pancreatitis Difficult cannulation Pancreatic duct contrast injection Balloon dilatation of biliary sphincter Possible Female Low volume of ERCP performed Absent CBD stone
- 14. ENDOSCOPIC ASSESSMENT OFSMALL BOWEL (ENTEROSCOPE ) Indications : • GI blood loss –with recurrent iron deficiency anemia (occult hemorrhage)/recurrent overt blood loss per rectum (cryptic hemorrhage) in pt with normal OGD (with duodenal biopsies) & colonoscopy • Malabsorption • Exclusion of cryptic IBD- Crohn disease • Targeting lesions in imaging • Inherited polyposis syndrome
- 15. TECHNIQUE 1) STANDARD ENTEROSCOPE– may reach in proximal small bowel • Requires 45 minutes • May be uncomfortable – requires sedation • Long thin endoscope inserted transnasally into stomach & pushed through pylorus with gastroscope passed through mouth • Carried distally by peristalsis propels balloon inflated at tip • Limitations – long examination time (6-8 hours), discomfort to patient, danger of perforation
- 17. • If areaof interest was outside reach of standard enteroscope , direct access via enterotomy • Advance technique of small bowel assessment : • Capsule endoscope allows diagnostic mucosal view of entire small bowel • Single/double-balloon enteroscopy – endoscopic access to entire small bowel for biopsy & therapeutics
- 18. 2) CAPSULE ENDOSCOPY •Requires 3 components : • Indigestible capsule • Portable data recorder • Workstation equipped with image-processing software
- 20. • Provides goodvisualisation from mouth to colon with high diagnostic yield • ‘Gold standard’ for GI bleeding • Contraindications : • Small bowel strictures – may cause acute obstruction requiring retrieval at laparotomy / via laparoscopy • Gastroparesis • Pseudo-obstruction
- 21. 3) SINGLE/DOUBLE-BALLOON ENTEROSCOPY •Direct visualisation & therapeutic intervention for entire small bowel via oral / rectal route • Developed in Japan 2001 – thin enteroscope & overtube both fitted with a balloon
- 23. Technique Advantages Disadvantages Traditionalenteroscopy • Simple technique with wide availability • Full range of therapeutics available • Performed under sedation • Some discomfort • Can only access proximal small bowel Capsule endoscopy • Able to visualise the entire small • Preferable • No sedation • Painless • No biopsies • Not controllable & no accurate localisation • Variable transit • Incomplete studies due to battery life • Not suitable for patients with strictures • Large capsule to swallow Double/single-balloon enteroscopy • Able to visualise the entire small bowel • Full range of therapeutic • Requires sedation/general anaesthesia • Patient discomfort • May take 3-4 hours, require admission • Complications - perforation
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- 25. COLONOSCOPY • Colonoscopy letsthe physician look inside the entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. • The procedure is used to look for early signs of cancer in the colon and rectum, inflamed tissue, abnormal growths, ulcers, and bleeding. • If anything abnormal is seen in the colon, like a polyp or inflamed tissue, the physician can remove all or part of it using tiny instruments passed through the scope. That tissue (biopsy) is then sent to a lab for testing. If there is bleeding in the colon, the physician can pass a laser, heater probe, or electrical probe, or inject special medicines through the scope and use it to stop the bleeding.
- 26. INDICATIONS OF COLONOSCOPY •Rectal bleeding with looser/more frequent +/- abdominal pain related to bowel action • Iron deficiency anemia (after biochemical confirmation +/- negative coeliac serology) : oesophagogastroduodenoscopy & colonoscopy • Right iliac fossa mass if U/S suggest colonic origin • Change in bowel habit associated with fever/elevated inflammatory response • Chronic diarrhoea (6 weeks) after sigmoidoscopy/rectal biopsy & negative coeliac serology • Follow-up of colorectal cancer & polyps • Screening of patients with family history of colorectal cancer • Assessment/removal of a lesion seen in radiological examination • Assessment of ulcerative colitis/Crohn extent & activity • Surveillance of IBD • Surveillance of acromegaly/ureterosigmoidostomy
- 28. COMPLICATIONS OF COLONOSCOPY Absolute: Suspected perforation of intestine Signs of peritonitis in toxic patient Relative : Severe acute colitis Gross acute gastrointestinal bleeding Poor bowel preparation Recent surgical anastomosis Partial or complete intestinal obstruction Abdominal or iliac aneurysm
- 29. SIGMOIDOSCOPY • To lookat the inside of the large intestine from the rectum through the last part of the colon : sigmoid or descending colon Indications : • To find the cause of diarrhea, abdominal pain, or constipation • To look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. • Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon two-thirds of the colon
- 32. ENDOSCOPIC ULTRASOUND (ECHOENDOSCOPE) •Disadvantage of conventional endoscopy : limited to mucosal surface • Not possible to diagnose submucosal / extraintestinal pathology Types of echoendoscope: • Radial echoendoscope : radially arranged U/S probe & forward – viewing lens, diagnostic of local tumour of esophagus & stomach • Linear echoendoscope : side viewing scope which is linearly arranged U/S probe, for sampling of tissues ; eg : paraesophageal & celiac nodes
- 33. INDICATIONS FOR ENDOSCOPICULTRASOUND Diagnostic Staging of esophageal/gastric malignancy Staging of hepatobiliary malignancy Diagnosis of choledochal microlithiasis Therapeutic Biopsy of paraesophageal LN Biopsy of submucosal upper GI lesions Biopsy of pancreaticobiliary mass Biopsy of portal lymphadenopathy Biopsy of left adrenal & left liver massess Transgastric drainage of pancreatic pseudocyst Celiac plexus block
- 34. IMPROVED ENDOSCOPIC IMAGING Chromoendoscopy,narrow band imaging & high resolution magnification endoscopy • Chromoendoscopy – topical application of stains / pigments to improve tissue localisation, characterisation / diagnosis • Agents that is used : methylene blue (vital), indigo carmine (contrast) & India ink (tattooing), acetic acid & Lugol’s iodine • Narrow band imaging – uses 2 discrete band of lights to increase contrast image of tissue surface • High resolution magnification endoscopy – to achieve near cellular definition of mucosa for surveillance of neoplasia
- 35. Duodenal adenoma on whitelight Clearly delineate with narrow band imaging Chromoendoscopy with indigo carmine
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- 37. BRONCHOSCOPY • A bronchoscopeis a tube with a tiny camera on the end which is inserted through the nose (or mouth) into the lungs. During a bronchoscopy procedure, a scope will be inserted through the nostril until it passes through the throat into the trachea and bronchi. A bronchoscope is used to provide a view of the airways of the lung. The scope also allows the doctor to collect lung secretions and lung tissue for biopsy for tissue specimens.
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- 39. CYSTOSCOPY • Cystoscopy isa procedure that uses a flexible fiber optic scope inserted through the urethra into the urinary bladder. • The bladder is filled with water and the interior of the bladder is inspected. • The image seen through the cystoscope may also be viewed on a color monitor and recorded on videotape for later evaluation.
- 40. SUMMARY • The definitionof endoscopy and endoscope • Upper & lower GI endoscopy • The indication for diagnostic and therapeutic endoscopy/ colonoscopy/ endoscopic retrograde cholangiopancreatography • The recognition and management of complications • Briefly on other types of endoscopy • Endoscopic ultrasound • Respiratory • Cystoscopy
- 41. References • Bailey &Love’s H. B., & M. L. (2018). Short Practice of Surgery(27th ed., Vol. 1). Boca Ratonca : CRC Press • M., S. B. (2016). SRBs Manual of Surgery : Jaypee Brothers Medical P.